Premenstrual Dysphoric Disorder (PMDD) is a severe and debilitating condition classified under depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is characterized by cyclic mood symptoms such as irritability, anger, affective lability, anxiety, and depressive feelings that emerge during the luteal phase of the menstrual cycle and remit with the onset of menstruation (1). Affecting approximately 3% to 8% of menstruating women globally, PMDD is more than a hormonal disturbance it is a serious psychiatric disorder that significantly impairs daily functioning, interpersonal relationships, and overall quality of life (2). Unlike the more common premenstrual syndrome (PMS), PMDD involves marked emotional and behavioral symptoms severe enough to interfere with occupational, academic, and social activities.

An important yet often underexplored aspect of PMDD is its association with psychiatric comorbidities. Studies have consistently found a higher prevalence of mood disorders, particularly major depressive disorder (MDD), dysthymia, generalized anxiety disorder, and even post-traumatic stress disorder among women diagnosed with PMDD (3). These comorbid conditions can intensify the symptom burden and complicate treatment strategies, often leading to chronicity and decreased responsiveness to standard pharmacological interventions. Despite the clinical significance of these comorbidities, many studies have focused primarily on the diagnostic criteria or pharmacological treatment of PMDD, often overlooking its broader psychosocial consequences (4).

In terms of quality of life (QoL), women with PMDD report impairments across multiple domains, including emotional well-being, social relationships, work productivity, and physical health (5). However, the role of psychiatric comorbidities in further reducing quality of life in PMDD patients remains inadequately studied. While some research acknowledges that mood and anxiety disorders may coexist with PMDD, there is limited data that systematically evaluates how these comorbidities impact specific QoL dimensions. Studies from, Steiner et al. (2003) and Freeman et al. (2004) have emphasized the efficacy of SSRIs in symptom reduction, but few studies assess how such interventions affect holistic well-being in patients with dual diagnoses (6, 7). Moreover, many studies fail to capture culturally sensitive dimensions of distress, particularly in non-Western populations, where psychosocial roles and stigma associated with menstruation and mental illness may further worsen outcomes.

This lack of integrated research creates a critical gap in understanding the lived experience of women suffering from PMDD, especially those with additional psychiatric conditions. Bridging this gap is essential for developing effective management plans that go beyond symptom suppression to address the broader psychosocial and emotional needs of patients. Therefore, the present study aims to investigate the prevalence of psychiatric comorbidities among women diagnosed with PMDD and to evaluate the impact of these comorbidities on various domains of quality of life. The study seeks to contribute a nuanced understanding of the interrelationship between mental health disorders and PMDD, which may help refine diagnostic approaches and promote comprehensive, individualized treatment strategies.

This was a cross-sectional, observational study conducted at the Department of Psychiatry, Gandhi Medical College, Hyderabad, Telangana. The study was carried out over the year 2023 with the objective of assessing psychiatric comorbidities and their impact on quality of life in women diagnosed with Premenstrual Dysphoric Disorder (PMDD).

Sample Size and Sampling Method

A total of 200 women aged between 18 and 45 years, attending the psychiatry outpatient services and meeting the DSM-5 criteria for PMDD, were enrolled using a purposive sampling technique. Informed written consent was obtained from all participants prior to inclusion.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Women aged 18–45 years
• Diagnosed with PMDD according to DSM-5 criteria
• Regular menstrual cycles over the past six months

Exclusion Criteria:

• Women with chronic physical illnesses (e.g., diabetes mellitus, hypertension)
• Pregnancy or postpartum period
• History of major gynecological surgeries (e.g., hysterectomy)
• Current use of hormonal therapy or psychotropic medication for other psychiatric disorders

Diagnostic Tools and Instruments

• PMDD Diagnosis: Structured clinical interview based on DSM-5 criteria
• Psychiatric Comorbidities: Assessed using the Mini International Neuropsychiatric Interview (MINI), a validated structured diagnostic interview
• Quality of Life: Measured using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale, which covers four domains: physical health, psychological health, social relationships, and environmental factors

Data Collection Procedure

• Participants were screened at the psychiatry outpatient department of Gandhi Medical College, Hyderabad.
• Eligible women (aged 18–45 years) were identified based on DSM-5 diagnostic criteria for PMDD.
• Informed written consent was obtained from all participants before inclusion in the study.
• A semi-structured proforma was used to collect sociodemographic data, menstrual history, and relevant clinical details.
• The Mini International Neuropsychiatric Interview (MINI) was administered to assess psychiatric comorbidities such as depression, anxiety, and substance use disorders.
• The WHOQOL-BREF questionnaire was used to evaluate the quality of life across four domains:
• Physical health
• Psychological well-being
• Social relationships
• Environmental factors
• All tools and interviews were conducted in English or Telugu as per the participant’s preference.
• Interviews and assessments were conducted during the luteal phase of the menstrual cycle to confirm timing and symptom consistency.
• Data collection was done by trained mental health professionals under supervision.
• Confidentiality and anonymity were ensured throughout the process.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 25. Descriptive statistics (mean, standard deviation, frequencies, and percentages) were used to summarize the demographic and clinical characteristics. Chi-square test was used for categorical variables, and t-tests or ANOVA were applied for continuous variables to compare quality of life scores across groups with and without psychiatric comorbidities. A p-value of less than 0.05 was considered statistically significant.

Ethical Considerations

Ethical clearance for the study was obtained from the Institutional Ethics Committee of Gandhi Medical College, Hyderabad. Confidentiality and privacy of participants were strictly maintained throughout the study.

Table 1: Demographic Profile, Menstrual History, and Clinical Characteristics of Study Participants (N = 200)

The demographic and clinical profile of the study participants (N = 200) is summarized in the table. The mean age of the women was 29.6 years (SD ± 6.2), with all participants being female. The average age at menarche was 12.7 years, indicating normal pubertal onset. The mean menstrual cycle length was 28.5 days, and the average duration of menstrual bleeding was 4.9 days, both falling within the typical physiological range. On average, participants had been experiencing PMDD symptoms for 3.8 years, and reported 5.4 symptomatic cycles in the last six months, confirming the chronic and recurring nature of the disorder. The severity of PMDD symptoms, as self-rated on a 0–10 scale, averaged 7.2, suggesting a moderate to high symptom burden. The mean Body Mass Index (BMI) of the participants was 23.5 kg/m², which is within the normal range (Table 1)

Table 2: Psychiatric Comorbidities among PMDD Participants (assessed using MINI)

The table 2 presents the distribution of psychiatric comorbidities among the 200 women diagnosed with PMDD. Major Depressive Disorder (MDD) was the most common comorbidity, observed in 32% of participants, followed by Generalized Anxiety Disorder (26%) and Panic Disorder (10.5%). Other comorbidities included Dysthymia (9%), Post-Traumatic Stress Disorder (7%), and Substance Use Disorder (5%). Less commonly reported were Social Phobia (3.5%) and Obsessive Compulsive Disorder (2.5%). Notably, 39.5% of the participants did not have any diagnosable psychiatric comorbidity based on the MINI interview. These findings suggest a high prevalence of mood and anxiety disorders among women with PMDD, highlighting the importance of routine psychiatric assessment in this population.

Table 3: WHOQOL-BREF Quality of Life Scores among Study Participants (N = 200)

The quality of life of participants was assessed using the WHOQOL-BREF questionnaire across four domains. The physical health domain had a mean score of 52.6 ± 12.4, indicating a moderate level of functioning in terms of energy, sleep, and mobility. The psychological well-being domain showed a slightly lower mean of 48.3 ± 13.1, suggesting a notable impact on emotional state, body image, and mental clarity. The social relationships domain had the lowest average score of 46.9 ± 14.5, reflecting difficulties in personal relationships and social support. The environmental domain recorded a relatively higher mean score of 54.1 ± 11.8, suggesting relatively better perceptions of safety, access to resources, and living conditions (Table 3).

Table 4: Comparison of WHOQOL-BREF Domain Scores Between PMDD Participants with and Without Psychiatric Comorbidity (N = 200)

This table 4 compares the mean quality of life scores across the four WHOQOL-BREF domains between women with and without psychiatric comorbidities. Participants with comorbid conditions reported significantly lower scores in all domains. The psychological domain showed the greatest difference, with those having comorbidities scoring 44.5 ± 12.9 compared to 54.1 ± 11.4 in those without (p < 0.001). Similarly, significant reductions were noted in physical health (p < 0.001), social relationships (p < 0.001), and environmental factors (p = 0.001) among those with psychiatric comorbidities. These results indicate that the presence of additional mental health disorders in PMDD patients substantially worsens their perceived quality of life, especially in emotional and social functioning.

Table 5: Correlation between PMDD Symptom Severity and WHOQOL-BREF Domain Scores

Table 5 shows the correlation between the severity of PMDD symptoms (self-rated on a 0–10 scale) and quality of life scores across the four WHOQOL-BREF domains. A moderate negative correlation was observed for both psychological (r = -0.48) and physical health (r = -0.42) domains, indicating that higher symptom severity is associated with poorer functioning in these areas. The social relationships (r = -0.36) and environmental factors (r = -0.30) domains also showed significant mild to moderate negative correlations, suggesting that increased symptom burden negatively impacts social support and perceived environmental quality. All correlations were statistically significant (p < 0.001), highlighting that greater PMDD severity is consistently linked to reduced quality of life.

Table 6: Multiple Linear Regression Predicting Psychological Domain Score (WHOQOL-BREF)

                      R² = 0.42, Adjusted R² = 0.40, F (5, 194) = 27.9, p < 0.001

The model explains 42% of the variance in the psychological quality of life scores. The results show that depression (B = -7.82, p < 0.001), anxiety (B = -5.41, p < 0.001), and symptom severity (B = -1.25, p < 0.001) were significant negative predictors of psychological well-being. This suggests that the presence of depressive or anxiety disorders, as well as greater symptom severity, are associated with lower psychological quality of life scores. In contrast, age and BMI were not statistically significant predictors, indicating that these factors did not meaningfully influence psychological functioning in this study population. These findings underscore the impact of psychiatric comorbidity and symptom intensity on the psychological health of women with PMDD (Table 6).

This study aimed to assess the prevalence of psychiatric comorbidities in women with Premenstrual Dysphoric Disorder (PMDD) and evaluate their impact on quality of life. The findings reveal a high burden of psychiatric comorbidities, particularly major depressive disorder (32%), generalized anxiety disorder (26%), and panic disorder (10.5%), consistent with previous research indicating a strong overlap between PMDD and mood or anxiety disorders (8).

Our data demonstrate that participants with psychiatric comorbidities scored significantly lower across all four domains of the WHOQOL-BREF particularly in the psychological and physical health domains. This is in line with the findings of Steiner and Born (2000), who reported that comorbid mood disorders significantly worsen functional impairment in PMDD (9). Similarly, Young et al. (1998) emphasized that while pharmacological treatment may reduce core PMDD symptoms, overall quality of life often remains compromised due to associated psychiatric conditions (10).

In the present study, the independent samples t-test showed that women with comorbid psychiatric disorders had significantly lower mean scores in physical (p < 0.001), psychological (p < 0.001), social (p < 0.001), and environmental (p = 0.001) domains. These findings support earlier work by Kocsis et al. (2008), who found that depression in PMDD was the strongest predictor of poor psychological functioning and social impairment (11).

Using one-way ANOVA, we observed that the lowest psychological domain scores were among participants with major depressive disorder, followed by those with generalized anxiety disorder. This pattern indicates that depressive features may exert a more detrimental effect on psychological well-being than anxiety alone, as shown in earlier research (12).

Our correlation analysis confirmed a significant negative relationship between self-rated PMDD symptom severity and all WHOQOL-BREF domains, particularly psychological well-being (r = -0.48, p < 0.001). This mirrors findings by Lustyk et al. (2004), who reported that higher severity ratings were linked to reduced emotional and interpersonal functioning (13).

The multiple linear regression analysis showed that depression, anxiety, and symptom severity were significant negative predictors of psychological quality of life, explaining 42% of the variance. This supports the model proposed by Yonkers et al. (2008), which describes PMDD as a complex interaction of hormonal sensitivity and underlying affective disorders (14).

Despite these insights, the study has certain limitations. As a cross-sectional study, causality cannot be established. Data were collected from a single tertiary care center, which may limit generalizability. Self-reported symptom severity is also subject to recall and reporting bias.

This study highlights a high prevalence of psychiatric comorbidities among women with PMDD, which are significantly associated with lower quality of life across physical, psychological, social, and environmental domains. Depression, anxiety, and symptom severity emerged as key predictors of poor psychological well-being. These findings underscore the need for routine psychiatric screening in PMDD patients, and for integrated treatment approaches that target both mood symptoms and functional outcomes to improve overall well-being.

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